Delirium in children and adolescents — branching viva

Opening

Examiner: A four-year-old boy is on day three after cardiac surgery. He was extubated yesterday and was chatting with his parents, but today he does not recognise them, pulls at his central line, and alternates between agitation and drowsiness. He is on a weaning midazolam infusion. How do you frame this? ^[6]

Candidate: I would treat this as probable delirium and a safety concern. The picture is acute, fluctuating, and involves impaired attention and a disrupted sleep–wake cycle in the context of critical illness and sedative exposure. I would screen with the CAPD immediately, ensure his physical safety, and start a structured cause-finding workup. ^[6]

Branch 1 — diagnosis

Examiner: What features make this delirium rather than anxiety or pain? ^[6]

Candidate: The acute onset, the fluctuating course (he was fine yesterday), the impaired attention (not recognising his parents), the disrupted sleep–wake cycle, and the direct physiological context of cardiac surgery and sedative exposure. DSM-5-TR requires acute onset, fluctuation, impaired attention and awareness, and a medical cause — all present. The motoric subtype is mixed, with both hyperactive (pulling lines) and hypoactive (drowsy) features. ^[6]

Examiner (probe): Why might this be missed on a busy ward? ^[6]

Candidate: Hypoactive features are easily dismissed as comfortable or settled, and the fluctuating course means a single normal assessment never excludes delirium. This is why structured twice-daily CAPD screening matters — it catches the episodes that a one-off bedside assessment misses. ^[6]